Intestinal Parasitic Infections in Relation to Diarrhea and CD4 T

International Conference on Agricultural, Ecological and Medical Sciences (AEMS-2015) April 7-8, 2015 Phuket (Thailand)
Intestinal Parasitic Infections in Relation to
Diarrhea and CD4 T-cell Count among Saudi
Patients with Chronic Renal Insufficiency
1
Felwa A. Thagfan, 2Magda M. Sanad, 3Ebtesam M. Al Olayan, and
4
Nawal I. Al Hoshani

any organic system, diarrhea is one of its most important
clinical signs (4). Cryptosproridium; Cyclospora and Isospora
are important opportunistic emerging pathogens causing
diarrheal diseases. The outcome of infection by these parasites
is dependent on absolute CD4 T cell counts, with lower counts
being associated with more severe, more atypical, and a
greater risk of disseminated disease. Although the infections
with these parasites have a serious impact on the health of
hemodialysis patients, their routine diagnosis may be ignored
and their prevalence among Saudi dialysis patients has not yet
been studied adequately. So, the present study is meant to
highlight the prevalence of the opportunistic intestinal
parasites among Saudi hemodialysis patients presenting with
diarrhea, and its significance in relation to CD4 T- cell count.
Abstract—Chronic renal insufficiency (CRI) disease leads to
uremia and induces a state of immunodepression. Since the immune
system plays an important role in controlling parasitic diseases, so,
higher frequencies of infections can be expected among CRI patients.
In the present study, 33 hemodialysis diarrheic Saudi patients and 42
immunocompetent diarrheic controls were evaluated for infections
with opportunistic and other associating intestinal parasites and their
relevance to CD4 T- cell count and type of diarrhea. Results revealed
that among hemodialysis patients, high prevalence of
Cryptosporidium, Isospora belli, Cyclospora, microsporidia, G.
lamblia and Blastocystis hominis (36.3, 93.9, 30.3, 100.0, 45.4 and
90.9% respectively) was detected. Polyparasitism was more frequent
among hemodialysis diarrheic patients and was more closely
associated with chronic diarrhea and lower CD4 T cell count in
comparison to control group. These findings indicate the high
susceptibility of hemodialysis patients, specifically those with low
CD4 T cell count, to intestinal parasitic infections of which
cryptosporidiosis is life-threatening. So, screening for such
infections, should be requested from hemodialysis patients once
presented with diarrhea.
II. PATIENTS AND METHODS
A total of 33 adult patients (12 males and 21 females ; 16>60 years old) presenting with diarrhea and attending at the
dialysis unit at Prince Salman Center for kidney diseases were
included in the present study. A control group of 42
immunocompetent adults presenting with diarrhea at the
Outpatient Clinic (Ambulatory Care Services) of King Khalid
University Hospital with age and sex matched with dialysis
patients was included. Control patients have no history of
receiving specific treatment or immunosuppressive drugs and
have CD4 T cell count > 500 cells ⁄mm3.
Keywords—Intestinal parasitic infections, hemdialysis, diarrhea,
CD4 T cell count, Saudi Arabia
I. INTRODUCTION
T
HE immune system plays an integral part in controlling
and clearing parasitic diseases. The current widespread
use of immunosuppressive therapy, and the growing
population of individuals with immunocompromised states
have altered the pattern of some parasitic infections so as they
have become a major cause of global morbidity and mortality
than diseases produced by any other group of organisms (1).
Increased life expectancies and the resulting aging of many
human populations have increased the incidence of chronic
degenerative diseases, such as chronic renal insufficiency
(CRI) which leads to uremia (2) and immunodepression (3).
most commonly expressed as an increase in the incidence of
infections which are responsible for 48% of deaths in patients
with CRI (2). Although manifestations of CRI do not exempt
A. Methodology
All patients were subjected to: a) Full personal and medical
history using structured questionnaire, present and past history
of diarrhea and treatment. b) Collection of fecal samples and
microscopic examination of fecal smears stained with the
modified Ziehl-Neelsen staining method (Kinyoun's acid fast
stain) for identification of oocycts of the coccidian species as
described by Garcia (5), Trichrome staining for identification
of cysts and trophozoites of intestinal protozoa (5) and Quickmicrosporidian spores. c) Collection of blood samples and
counting of CD4-T-lymphocytes by flow cytometry ( Becton
Dickinson, Paramus, N.J., USA) as described by Dwivedi et
al. (6).
The study protocol was approved by the ethics review board
of King Saud University (King Khalid University Hospital ).
Informed consent from each patient was obtained. All the tests
were performed after due patient consent and in accordance
with the institutional ethical guide line.
1, 3, 4
Department of Zoology, College of Science, King Saud University,
Riyadh Saudi Arabia,
2
Department of Parasitology, Faculty of Medicine, Zagazig University,
Zagazig, Egypt,
Corresponding author: Magda M. Sanad2 , Professor of Medical
Parasitology, Faculty of Medicine, Zagazig University, Zagazig, Egypt,
e.mail: [email protected].
http://dx.doi.org/10.15242/IICBE.C0415042
62
International Conference on Agricultural, Ecological and Medical Sciences (AEMS-2015) April 7-8, 2015 Phuket (Thailand)
IOPs: intestinal opportunistic parasites. No. ex.: examined number. - No. +ve
: positive number. *Chi square test to compare between % of infection
**Student "t" test to compare between mean CD4 count
B. Statistical analysis
Data analysis was done using the Student (t) test, ChiSquare test and One Way ANOVA.
Immunosuppression has different consequences for the host
depending on its magnitude, and will alter the range of
pathogens to which they are susceptible (7). Parasites can
cause serious infections in immunocompromised hosts,
especially in patients with impaired cellular immunity (8).
Patients undergoing hemodialysis are at significant risk of
infection with opportunistic parasites (9).
Results of the present work showed that Cryptosporidium,
Isospora belli, Cyclospora, microsporidia, G. lamblia and
Blastocystis were highly prevalent among dialysis patients,
and still prevalent among diarrheic controls. This emphasizes
that these parasites are causative agents of diarrhea in
immunocompetent patients in addition of being opportunistic
parasites. The difference here is that urgent detection and
management are required for the dialysis patients because one
of these infections, i.e. cryptosporidiosis is life-threatening.
This is in accordance with Goetz et al. (10) who reported
microsporida infection in renal transplant recipients
undergoing immunosuppressive therapy. Similarly, Massry et
al. (11), Descomps and Chatenoud (12) and Chonchol (13)
stated that hemodialysis patients are susceptible to
opportunistic infections as a result of leukocyte dysfunction
and impaired immunologic response. Brenner (14) added that
parasitic infections are the second cause of mortality among
dialysis patients. Ocak and Eskiocak (15) mentioned that
chronic renal insufficiency is usually associated with uremia
that impairs antigen presentation, T-cell activation, and causes
impaired antibody production. Hazarati et al. (16) assumed
that increased time of uremic status might weaken immune
system progressively with resultant increased risk of infectious
disease.
Sanad and Al-Malki (17) found that the rate
of
Cryptospondium infection among kidney transplant patients
under immunosuppressive therapy was 84% which is much
higher than that detected in the present study in dialysis
patients. The
difference
between the
level
of
immunosuppression induced by the aggressive chemotherapy
protocols, usually followed up, in kidney transplant patients
(18, 19) and that induced in dialysis patients is most probably
expected to be the cause of this discrepancy. This can be
confirmed by the mean CD4 count obtained among dialysis
patients in the present study (995.4+530.8/mm3). Many
authors reported that Cryptosporidium infection is expected
among HIV patients at lower CD4 counts, mostly below
200/mm3 (20, 21).
In agreement with our results, Ferreira (22) reported that
among the most important protozoa that were incriminated for
causing severe diarrhea in the immunosuppressed patients
were Cryptosporidium parvum, Isospora belli, Cyclospora
cayetanensis and microsporidia. Similarly, Santana et al. (23)
stated that Cyclospora cayetanensis is a cause of clinical
disease in immunosuppressed hosts and added its relevance
with prolonged, severe and highly recurrent diarrhea. Certad et
al. (24) found that I. belli accounted for up to 20% of cases of
diarrhea in AIDS patients. Zali et al. (25) stated that
Blastocystis hominis has to be considered as an opportunistic
III. RESULTS AND DISCUSSION
Results are presented in tables 1-4.
TABLE I
PREVALENCE OF INTESTINAL OPPORTUNISTIC PARASITES AMONG
DIARRHEIC HEMODIALYSIS PATIENTS IN RELATION TO DIARRHEIC CONTROLS
IOPs: intestinal opportunistic parasites. - No. +ve: positive number.
* mixed infection with Cyclospora spp. and Isospora belli.
** mixed infection with Cryptosporidium spp.
*** mixed infection with Cryptosporidium spp. and Cyclospora spp.
**** ANOVA test
TABLE II
CD4 T-CELL COUNT AMONG HEMODIALYSIS INFECTED PATIENTS IN
RELATION TO INFECTED CONTROLS
IOPs: intestinal opportunistic parasites. * Chi square test
TABLE III
RELATIONSHIP BETWEEN CD4 T-CELL COUNT AMONG INFECTED
HEMODIALYSIS PATIENTS AND INFECTED CONTROLS
* hemodialysis patients ** Chi Square test *** All have mixed infection
TABLE IV
INTESTINAL PARASITIC INFECTIONS AND CD4 CELL COUNT IN RELATION TO
TYPE OF DIARRHEA AMONG HEMODIALYSIS PATIENTS
http://dx.doi.org/10.15242/IICBE.C0415042
63
International Conference on Agricultural, Ecological and Medical Sciences (AEMS-2015) April 7-8, 2015 Phuket (Thailand)
parasite and added that it was the second most prevalent in
HIV-infected patients in Iran, with most of the cases were seen
in patients with diarrhea. Seyrafian et al. (26) found that
11.5% dialysis patients were infected with Cryptosporidium
and were significantly higher than in control groups. They
added that cryptosporidiosis in the immunocompromised
individuals is usually associated with chronic diarrhea and
can be life threatening. Dwivedi et al. (6) identified enteric
opportunistic parasites among 62.7%
of HIV infected
individuals, of which Cryptosporidium, Giardia lamblia,
microsporidia and Isospora belli were significantly
associated with diarrhea. Evering and Weiss (8) found that
Cryptosporidium was the most common protozoon to be
encountered in immunocompromised patients. Domenech et
al. (27) recognized Cryptosporidium as a cause of diarrhea
associated with a high mortality in immunocompromised
patients.
In the present study, all of the dialysis patients were
infected with more than one parasite, a finding indicates the
high susceptibility of such patients to parasitic infections and
necessitates requests for intestinal parasites once presented
with diarrhea. However, our reference control group showed
also a high percentage of multiparasitic infections which
indicates that any diarrheic patient, even nonimmunosuppressed, has to be requested for intestinal parasites.
These results are in agreement with Graczyk et al. (28) who
stated that the presence of parasites in the gastrointestinal tract
modulates the immune response, predisposing to infection
with other enteropathogens and favoring multi-parasitism.
Dwivedi et al. (6) found that chronically infected diarrheal
patients had polyparasitic infections.
It is noticed that the infection rates of intestinal
opportunistic parasites in dialysis patients worldwide are
contradictory in comparison to each other and to our results.
This may be related to socioeconomic state, geographical
locality and population general health or may be a
consequence of the quality of drinking water and food
hygiene.
Among patients with chronic renal insufficiency , the rate of
infection with Cryptosporidium species was significantly
higher among patients with CD4- T cell count < 500/ mm3 in
comparison to patients with CD4 T-cell count > 500/ mm3.
The rates of infection with Cyclospora, Isospora and G.
lamblia (60%, 30%, 70% respectively) were insignificantly (P
> 0.05) higher among patients with CD 4 T-cell count <
500/mm3 in comparison to patients with CD4 T-cell count >
500/mm3 (47.05, 23.5, 58.8% respectively). On the other hand,
the rate of infection with microsporidia spp. was 100% among
all CRI patients with CD4 T-cell count < 500/mm3 or >
500/mm3 (100%).
It is apparent, from results of the present study, that low CD4
T cell count is associated with infections with opportunistic
intestinal parasites. Therefore, has to be continually checked
for, in people who are at risk.
Among patients with chronic renal insufficiency, 2/31 patients
had acute diarrhea. One of these two was infected with
Cryptosporidium and Blastocystis the other had infection with
Isospora belli, both were infected with microsporidia . Out of
33 with CRI, 31 had chronic diarrhea.
http://dx.doi.org/10.15242/IICBE.C0415042
In agreement with our results, Tuli et al. (29) found that
Cryptosporidium spp. was the most commonly acquired
protozoa
causing
chronic
diarrhea
among
immunocompromised patients in India, followed by
microsporidia. They added that the isolation rates decreased
with the increase in the CD4 cell counts. The CD4 levels were
inversely proportional to the duration of diarrhea and patients
with chronic diarrhea had lower CD4 counts than those who
had acute diarrhea.
In conclusion, the present study clarified that enteric
infections with opportunistic parasites are highly prevalent
among diarrheic hemodialysis patients and polyparasitism is
frequent. The outcome of infection is dependent on absolute
CD4 T cell counts, with lower counts being associated with
more severe disease. So, optimizing the immunologic status
of individuals at risk may help to reduce acquisition of such
opportunistic parasitic infections and the likelihood of
developing life-threatening diarrhea.
REFERENCES
[1]
[2]
[3]
[4]
[5]
[6]
[7]
[8]
[9]
[10]
[11]
[12]
[13]
[14]
[15]
64
Seyrafian, S.; Pestehchian, N.; Namdari ,N.; Aviani, M.; Kerdegari, M.;
Parvizian, F.; Kassaii, L.; Eshaghian, A. and Nasri, H. (2011):
Prevalence of Parasitic Infections in Iranian Stable Hemodialysis
Patients. Appl. Med. Inform., vol.29, No.3,p: 31-36.
Marques, A.B.; Pereira, D.C.; Ribeiro, R.C.and Motivos, H.M. (2005):
efreqüência de internação dos pacientes com IRC em tratamento
hemodialítico Arq Ciênc Saúde.,12(2):67-72.
Meijers, R.W.; Litjens, N.H.; de Wit, E.A.; Langerak, A.W.; van der
Spek, A.; Baan, C.C.; et al. (2012): Uremia causes premature ageing of
the T cell compartment in end-stage renal disease patients. Immun
Ageing., 9: 9-16.
http://dx.doi.org/10.1186/1742-4933-9-19
Barbosa, D.A.; Gunji, C.K.; Bittencourt, A.R.C.;et al. (2006): Comorbidade e mortalidade de pacientes em início de diálise. Acta Paul
Enferm., 19(3):304-9.
http://dx.doi.org/10.1590/S0103-21002006000300008
NKF-KDOQI. (2002): Clinical practice guidelines for chronic kidney
disease: evaluation, classification, and stratification. Am J Kidney Dis.,
39:S1-266.
Garcia, L.S. (2007): Diagnostic Medical Parasitology, 5th edition. ASM
Press. Washington, DC.
Dwivedi, K.K..; Prasad, G.; Saini, S.; Mahajan, S.; Lal, S. and Beveja,
U.K. (2007): Enteric Opportunistic Parasites among HIV Infected
Individuals: Associated Risk Factors and Immune Status. Jpn. J. Infect.
Dis., 76-81.
Evering, T. and Weiss, L. M. (2006): The immunology of parasite
infections in immunocompromised hosts. Parasite Immunol., 28(11):
549-565.
http://dx.doi.org/10.1111/j.1365-3024.2006.00886.x
Kulik, R.A.; MoráisFalaovigna, D.L.; Nishi, L. and Araujo, S.M. (2008):
Blastocystis sp. and other intestinal parasites in hemodialysis patients.
Braz.J.Infect. Dis. 2008;12(4):33841.
http://dx.doi.org/10.1590/S1413-86702008000400017
Goetz, M.; Eichenlaub, S. and Pape, G.R. and Hoffmann, R.M. (2001):
Chronic diarrhea as a result of intestinal microsposidiosis in a liver
transplant recipient. Transplantation., 71(2):334-7.
http://dx.doi.org/10.1097/00007890-200101270-00029
Massry, Y.G.; Alexiewicz, J.M. and Gacioug, Z. (1996): Secondary
hyperparathyroidism and immune system in chronic renal failure.
Semin- Nephrol., 2:186-201.
Descomps, L.B. and Chatenoud, L.(1996): T cells and B cells in chronic
renal Failure. SeminNephrol., 16;182-191.
Chonchol, M. (2006): Neutrophil dysfunction and infection risk in endstage renal disease. Semin Dial., 19(4):291-6.
http://dx.doi.org/10.1111/j.1525-139X.2006.00175.x
Brenner, B.M. (2008): Chronic renal failure. Brenner and Rector 's the
kidney. 8th edition volume 2; pp. 1193-4.
Ocak, S.H. and Eskiocak, A.F. (2008): The evaluation of immune
response
to
hepatitis
B
vaccination
in
diabetic
and
International Conference on Agricultural, Ecological and Medical Sciences (AEMS-2015) April 7-8, 2015 Phuket (Thailand)
[16]
[17]
[18]
[19]
[20]
[21]
[22]
[23]
[24]
[25]
[26]
[27]
[28]
[29]
nondiabetichaemodialysis patients and the use of tetanus toxoid.
Nephrol.,13:487
http://dx.doi.org/10.1111/j.1440-1797.2008.00936.x
Hazarati, K.H.; Gharavi, M.J.; Makhdoumi, K.; Rabat, M. and
Tagizadeh, A. (2006): Prevalence of Cyptosporidium spp. Infection in
Renal Transplant and hemodialysis patients. Iranian J Pubi Health.,
35(3):54-7.
Sanad ,M.M. and Al-Malki, J.S. (2007): Cryptosporidiosis among
immunocompromised patients in Saudi Arabia. J. Egypt. Soc. Parasitol.,
37: 765–774.
Bachur, T. P.; Vale, J. M. ; Coêlho, I. C. ; Queiroz, T. R. and Chaves, C.
D. S. (2008): Enteric parasitic infections in HIV/AIDS patients before
and after the highly active antiretroviral therapy. Braz. J. Infect. Dis.,
12:115-122.
http://dx.doi.org/10.1590/S1413-86702008000200004
Stock, P. G.; Barin, B.; Murphy, B.; Hanto, D.; Diego, J.M.; Light, J.;
Davis, C.; Blumberg, E.; Simon, D.; Subramanian, A.; Millis, J.M.;
Lyon, G.M.; Brayman, K.; Slakey, D.; Shapiro, R.; Melancon, J.;
Jacobson, J.M.; Stosor, V.; Olson, J.L.; Stablein, D.M. and Roland, M.E.
(2010): Outcomes of kidney transplantation in HIV-infected recipients.
N. Engl. J. Med., 363(21): 2004-2014
http://dx.doi.org/10.1056/NEJMoa1001197
Gupta, S.; Narang, S.; Nunavath, V. and Singh, S. (2008): Chronic
diarrhea in HIV patients: prevalence of coccidian parasite. Indian J.
Med. Microbiol., 26, 172–175.
http://dx.doi.org/10.4103/0255-0857.40536
Kulkarni, S. V.; Kairon, R.; Sane, S.S.; Padmawar, P.S.; Kale, V.A.;
Thakar, M.R.; Mehendale, S.M. and Risbud, A.R. (2009): Opportunistic
parasitic infections in HIV/AIDS patients presenting with diarrhoea by
the level of immunesuppression. Indian. J. Med. Res., 130(1): 63-66.
Ferreira, M. S. (2000): Infections by protozoa in immunocompromised
hosts. Mem. Inst. Oswaldo. Cruz., 95 Suppl 1: 159-162.
http://dx.doi.org/10.1590/S0074-02762000000700026
Santana Ane, M.; Nunez Fernandez, F. A.; Pérez Avila, J.;
BarreroBringuez, M. and Velázquez Viamontes, B. (2000): Emergence
of a new pathogen: Cyclospora cayetanensis in patients infected with
human immunodeficiency virus. Rev. Cubana. Med. Trop., 52(1): 6669.
Certad, G.; Arenas-Pinto, A.; Pocaterra, L.; Ferrara, G.; Castro, J.;
Bello, A. and Nunez, L. (2003): Isosporiasis in Venezuelan adults
infected with human immunodeficiency virus: clinical characterization.
Am. J. Trop. Med. Hyg., 69:217-222.
Zali, M. R.; Mehr, A. J.; Rezaian, M.; Meamar, A. R.; Vaziri, S. and
Mohraz, M. (2004): Prevalence of intestinal parasitic pathogens among
HIV-positive individuals in Iran. Jpn. J. Infect. Dis., 57:268-270.
Seyrafian, S.; Pestehchian, N.; Kerdegari, M.; Yousefi, H. A. and
Bastani, B. (2006): Prevalence rate of Cryptosporidium infection in
hemodialysis patients in Iran. Hemodial. Int., 10:375-379.
http://dx.doi.org/10.1111/j.1542-4758.2006.00133.x
Domenech, C.; Rabodonirina, M.; Bleyzac, N.; Pagès, M.P. and
Bertrand, Y. (2011): Cryptosporidiosis in children with acute
lymphoblastic leukemia on maintenance chemotherapy. J. Pediatr.
Hematol. Oncol., 33(7): 570-572.
http://dx.doi.org/10.1097/MPH.0b013e31820e2d3a
Graczyk, T. K.; Shiff, C. K.; Tamang, L.; Munsaka, F.; Beitin, A.M. and
Moss, W.J. (2005): The association of Blastocystis hominis and
Endolimax nana with diarrheal stools in Zambian school-age children.
Parasitol. Res., 98(1): 38-43.
http://dx.doi.org/10.1007/s00436-005-0003-0
Tuli, L.; Gulati, A. K.; Sundar, S. and Mohapatra, T.M. (2008):
Correlation between CD4 counts of HIV patients and enteric protozoan
in different seasons - an experience of a tertiary care hospital in Varanasi
(India). BMC Gastroenterol., 8: 36.
http://dx.doi.org/10.1186/1471-230X-8-36
http://dx.doi.org/10.15242/IICBE.C0415042
65